Nigerian Journal of Ophthalmology 2008; 16(1): 16-19

Indications for Surgical Removal of the in Irrua, Nigeria

ME Enock,12 AE Omoti, UC Fuh, 1 AA Alikah1 1Irrua Specialist Teaching Hospital, Irrua, Edo State , Nigeria 2University of Benin Teaching Hospital, Benin City, Edo State, Nigeria

SUMMARY There are three methods of removal of the eyeball. First is evisceration, which is removal of the intraocular contents Objective: To determine the reasons for removal of the eye at the leaving only the scleral shell. The second method is Irrua Specialist Teaching hospital, Irrua, Edo State, southern enucleation which involves the removal of the whole intact Nigeria. eye by cutting the six extra-ocular muscles and transecting the Method: A retrospective study of all cases of enucleation and optic nerve. The third is exenteration, which is removal of the evisceration carried out over a 10-year period – July 1997 to entire orbital contents down to the bone. It is a mutilating June 2007 – at the Irrua Specialist Teaching Hospital. Data operation and is only indicated in the treatment of extensive from theatre records and case notes were analysed with malignant tumours in the . Exenteration is, however, no respect to age, sex, interval between onset of symptoms and longer popular due to availability of radiotherapy. presentation, indications for surgery and type of surgery Previous similar studies in Ibadan and Benin City showed done. that infection, trauma and tumours were the major reasons for Results: A total of 42 patients had enucleation or evisceration the removal of the eyeball.1,2 In Gambia, infection, staphyloma during the period, accounting for 6.96% of all ophthalmic and tumours were the commonest causes.3 However, in surgeries (603) over the same period. Eight were Lagos, tumours, chronic inflammatory diseases and painful enucleated (19.05%) and 34 eyes were eviscerated (80.95%). blind eye secondary to were found to be the There were 21 males (50%) and 21 females (50%). The most commonest reasons for enucleation.4 In Sagamu, trauma, common reason for removal of the eye was a ruptured panophthalmitis and malignant tumours were the most secondary to severe ocular trauma (35.71%). This was common causes;5 whereas in Onitsha, infections, trauma and followed by panophthalmitis (26.19%) and intraocular tumours were the commonest causes.6 In other tumours (9.52%). Forty patients (95.2%) presented after one developing countries, tumours and trauma were the most week of onset of ocular lesions; 20(47.6%) had used common indications for destructive .7-9 In traditional eye medication, and 4 (9.5%) had used eye drops developed countries, on the other hand, tumours and painful containing corticosteroids. blind eyes were the most frequent causes.10-13 Conclusion: Health education programmes aimed at increasing Most of the events leading to removal of the eyeball are public awareness on dangers of self medication, the use of preventable. This study reviews the reasons for enucleation native medication and the need to present early to hospital are and evisceration at the Irrua Specialist Teaching Hospital, highly recommended. Also, protective goggles and helmets Irrua, a sub-urban tertiary health institution of Edo State, with plastic facial coverings are recommended for workers Nigeria, over a ten-year period (July 1997 – June 2007) and to who are at risk for eye trauma. compare the findings with other hospitals in Nigeria and elsewhere. Key words: eye, enucleation, evisceration, Nigeria PATIENTS AND METHODS The case notes of all the patients who had an eye removed at INTRODUCTION Irrua Specialist Hospital during the 10-year study period were When an eyeball is removed, the effect is not only uniocular retrieved and information on age, gender, diagnosis, interval blindness, but there is also a cosmetic blemish with associated between onset of symptoms and presentation, use of negative effects on the psychological and physical state of that traditional medication or self medication and modality of individual. Usually, removal of the eyeball is resorted to only treatment were recorded. The results were analysed using the when an eyeball or vision can no longer be salvaged.

*Correspondence: Dr. ME Enock, Irrua Specialist Teaching Hospital, Irrua, Edo State , Nigeria; E-mail: [email protected] Indications for Surgical Removal of the Eye in Irrua, Nigeria

EPI-INFO version 6 software. Discrete variables were Table 3. Yearly distributions of enucleation and evisceration expressed as percentages and displayed on frequency tables. Year Number of Surgeries % Frequency 1 1 2.39 RESULTS 2 3 7.1 A total of 42 patients had enucleation or evisceration during 3 2 4.76 the study period. This accounted for 6.97% of the total number 4 4 9.52 of ophthalmic surgeries (603) performed during the period. 5 3 7.14 Eight eyes were enucleated (19.05%) and 34 eyes were 6 4 9.52 eviscerated (80.95%). There were 21 males (50%) and 21 7 5 11.90 females (50%). Table 1 shows the age and sex distribution of 8 5 11.90 the patients. Eleven patients (26.2%) were between 71-80 years 9 8 19.04 and 5 patients (11.9%) were aged 10 years and below. 10 7 16.67 Total 42 100.0 Table 1. Age and sex distribution of patients Age Male Female Total % Frequency Twenty patients (47.6%) comprising of 12 males and 8 (years) females had used traditional eye medication (TEM) prior to <10 3 2 5 11.9 presentation. Also, 4 patients (9.5%) – 3 males and 1 female – 11-20 3 1 4 9.5 had used eye drops containing steroids prior to presentation. 21-30 1 2 3 7.1 One patient (2.4%), a child presented with 31-40 2 2 4 9.5 secondary to a broomstick injury at school. Seven patients (16.7%), all above 60 years, had mild ocular 41-50 3 3 6 14.3 trauma on the farm which progressed to panophthalmitis. 51-60 1 3 4 9.5 Two patients (4.8%) presented within one week of onset 61-70 3 2 5 11.9 of symptoms of the disease process, but with severe 71-80 5 6 11 26.2 panophthalmitis and visual loss. Twenty-six patients (61.9%) presented between one week and one month of the disease Total 21 21 42 100.0 process, while fourteen patients (33.3%) presented between two months to several years of the injury or disease onset. Table 2 shows the reasons for enucleation and evisceration. Fifteen eyes (35.7%) were removed due to a ruptured globe secondary to severe ocular injury (trauma). DISCUSSION This was followed by panophthalmitis with 11 eyes (21.19%). The decision to remove an eyeball is usually a difficult one for Table 3 shows the yearly distribution of enucleation and both the surgeon and the patient.3 Hence, it is the last option evisceration carried out over the period. There was an average for the surgeon and the patient when all other efforts to of 3 surgeries per year between 1997 and 2002. This doubled salvage the eye have failed. For the patient, the loss is to 6 surgeries per annum between 2003 and 2007. enormous since any form of artificial replacement of the organ is usually functionless (vision wise). At best, an improved Table 2. Causes of enucleation or evisceration cosmetic appearance is all that is achieved.3 Causes Enucleation Evisceration Total Frequency The most common reason for removal of the eye in this % study was trauma (35.71%). This was followed by Ruptured globe panophthalmitis (26.19%) and then intraocular tumours (trauma) 1 14 15 35.7 (9.52%). This trend is similar to a study done at Sagamu, in which trauma, panophthalmitis and malignant tumours were Panophthalmitis/ Endophthalmitis 0 11 11 26.2 found to be the most common indications for destructive eye surgery.5 Trauma was also the leading cause for the removal Intraocular 8,9,14,15 tumours 4 0 4 9.5 of the eye in other previous similar studies. Severe perforating ocular injury with visual loss was the Staphyloma 0 4 4 9.5 most important reason for eye removal in this study. This Painful blind eye 2 2 4 9.5 could be due to the fact that the Irrua Specialist Teaching 1 3 4 9.5 Hospital, which is situated along the very busy Benin-Abuja Total 8 34 42 100.0 highway, is the nearest and most easily accessible tertiary

17 ME Enock, AE Omoti, UC Fuh, AA Alikah hospital for road traffic accident victims in that area (Edo In patients with staphyloma, the eyes were removed for central, Edo north and parts of Ondo and Kogi states). Also, cosmetic reasons. Two of these cases were due to trauma that motorcycle-related road traffic accidents are an important occurred some years earlier when the patients were young. cause of ocular injury in the environment. This is due to the This is similar to the findings by the study in India.7 The other fact that students of Ambrose Alli University, which is just two admitted to having had an eye infection when they were about 5km from Irrua, use motorcycles as means of transport also young. This infection could be due to measles. However, to and from their hostels. It was observed that motorcycle- measles is no longer a common cause of staphyloma as shown related ocular injury is an important cause of ocular morbidity by an earlier study, due to the impact of the National in Irrua.16 Panophthalmitis was the next most frequently- Programme on Immunization.2 found reason for removal of the eye in this study. In some Of the four painful blind eyes that were removed were other studies, however, it was the commonest reason for removed, three were due to intractable glaucoma. The cause removal of the eye.1-3,6 It appears to be the end-stage of a in the fourth case was ocular trauma many years prior to process which may have started out as a minor trauma, or presentation. from the use of traditional eye medication (TEM), or from Eyes were removed in four cases of phthisis bulbi for delayed treatment of minor conditions such as conjunctivitis.3 cosmetic reasons. Previous trauma was the cause of the The use of TEM contributed in no small measure to the phthisis bulbi. disastrous outcome of some of the eyes.3,6 Irrua, though a sub- The male to female ratio of 1:1 in this study is similar to urban community, is still largely rural in terms of the study in Zaire that had a male: female ratio of 1.2:1.9 development, hence traditional eye healers abound. Mild More surgeries were carried out in the last four years due ocular trauma, which could have healed easily with adequate to the presence of a full-time consultant ophthalmologist. The treatment, will eventually progress to corneal ulcers and then first 6 years recorded lower surgical output because the panophthalmitis due to the harmful effects of traditional eye hospital only had two visiting ophthalmologists who ran medication. Loss of the eye from panophthalmitis, following clinics twice a week. The presence of a full-time the use of harmful traditional eye medicines, has been ophthalmologist has attracted more referrals. 2,3,6,7 documented. In conclusion, most of the reasons for the removal of the Also, some patent medicine dealers dispense steroid eye eye in this study were preventable. Public heath drops to patients with mild corneal abrasion which may enlightenment campaigns need to be intensified by the progress to ulceration and panophthalmitis. This was primary health departments of the local government in order 6 highlighted in a previous study in Onitsha. In the present to educate the rural populace on the need to present early to study, four of the eleven cases of panophthalmitis admitted to hospital, and on the harmful effects of traditional eye having used steroid eye drops after mild ocular trauma. medications (TEM). School health programmes should lay Incidentally, three of the patients were given the steroid drops more emphasis on eye health. Close supervision of children at by an optician practicing in a nearby town. home and at school when playing to prevent them sustaining The causes of mild ocular trauma progressing to eye injuries cannot be overemphasized. Government, as a panophthalmitis due to the harmful effect of traditional eye matter of urgency, should enact a law to prevent medication or steroids as seen in this study include, broom advertisement by traditional eye healers. In addition, stick injury in a child and injuries sustained while working on government should also fine/punish reckless motorists and the farm. Mild injuries sustained during farm work were the ensure that the roads are in good condition. Protective goggles causes of seven cases of panophthalmitis in the patients above or helmets with plastic facial coverings are recommended for 60 years of age. Such elderly people in the environment of this people at risk of ocular injury, such as farmers and motorcycle study rely strongly on traditional eye medication and will riders. usually use them before presentation, by which time panophthalmitis would have set in. ACKNOWLEDGEMENT Intraocular tumours, staphyloma, painful blind eye and phthisis bulbi were the other reasons for removal of the eye in We wish to acknowledge the secretarial assistance of Miss this study. Vivian Iyoha for the typesetting of the manuscript. was the main intraocular tumour that necessitated removal of the eye in this study. All cased were found in children below the age of 10 years. Two of these REFERENCES presented early with a ‘cat’s eye reflex and are still alive till 1. Baiyeroju-Agbeja AM, Ajibade HA. Causes of removal of the today. Retinoblastoma was also the most common intraocular eye in Ibadan. Nig J Surg 1996; 30: 33-40. tumour in previous similar studies. 1-4,7,10,11,12

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